Contextul actual al serviciilor de sanatate

Sanatatea populatiei este o problema importanta,care necesita o atentie sporita la nivel national, fiind in acelasi timp o problema de actualitate la nivel european si mondial

Starea de sanatate este influentata in mare masura de calitatea serviciilor medicale, de rapiditatea interventiei si de masura in care pot fi adresati un numar cat mai mare de pacienti simultan

Contextul actual al serviciilor de sanatate

Nevoia de ingrijire la domiciliu in crestere Sistemul medical se confrunta cu o insuficienta critica a resurselor publice si cu o lipsa importanta de personal de specialitate (asistenti medicali, medici) Sistemul de sanatate si furnizorii de servicii medicale sunt fortati sa ofere servicii de o calitate tot mai ridicata care sa aduca beneficii clinice, in conditiile in care fondurile alocate de Casa de Sanatate sunt reduse, implicit costurile per pacient

Contextul actual al serviciilor de sanatate

Furnizorii de asistenta medicala se confrunta cu o serie de provocari: - cresterea costurilor serviciilor de sanatate - cresterea importantei calitatii serviciilor medicale si siguranta pacientului - schimbarile demografice si imbatranirea populatiei - lipsa de personal si reducerea bugetelor - cresterea consumerismelor pacientilor - cresterea asteptarilor pacientilor privind calitatea serviciilor medicale - dezvoltarea serviciilor de ingrijire la domiciliu

Contextul actual al serviciilor de sanatate

Reactii la provocarile sistemului de sanatate: - etapa I: AUTOMATIZARE (1995) - administrarea sistemelor: - inregistrarea pacientilor - costuri - achizitii - cerere electronica, verificarea eligibilitatii - inregistrarea membrilor

Contextul actual al serviciilor de sanatate

Reactii la provocarile sistemului de sanatate - etapa II: DIGITIZARE (2005) - fisa pacientului: Electronic Health Record- HER - comenzi ale medicilor (Computerized Physician Order Entry CPOE) - card de sanatate (Consumer Smart Card) - reteta electronica (ePrescribing) - flux de pacienti (E-Clinical WorkFlow) - mijloace de suport pt medici in luarea deciziilor - comunicarea doctor-pacient

Contextul actual al serviciilor de sanatate

Reactii la provocarile sistemului de sanatate - etapa III: INFORMATIZARE (2015) - personal health records(PHR) gestionate de pacient - monitorizare la distanta a pacientilor/asistenta la domiciliu - telehealth - servicii suport pt cetateni - Health Advocate

Actiuni la nivelul statelor membre UE - consolidarea increderii si acceptarea serviciilor de

telemedicina - stabilirea de normative legale clare - rezolvarea problemelor tehnice si facilitarea dezvoltarii serviciilor medicale in aceasta directie - Susteins- initiativa EU pentru implementarea accesului pacientului la propriile inregistrari medicale pana in 2015

http://ec.europa.eu/information_society/activities/health/policy/telemedicine/ind ex_en.htm COMUNICARE A COMISIEI EUROPENE CTRE PARLAMENTUL EUROPEAN CONSILIU, COMITETUL ECONOMIC I SOCIAL EUROPEAN I COMITETUL REGIUNILOR privind telemedicina i beneficiile sale pentru pacieni, pentru sistemele de sntate i pentru societate (Bruxelles, 4.11.2008 COM(2008)689 ): Telemedicine can improve access to specialised care in areas suffering from a shortage of expertise, or in areas where access to healthcare is difficult. Telemonitoring can improve the quality of life of chronically ill patients and reduce hospital stays. Services such as teleradiology and teleconsultation can help to shorten waiting lists, optimise the use of resources and enable productivity gains. Telemedicine can also make a significant contribution to the EU economy The use of telemedicine services is still limited, and the market remains highly fragmented. Although Member States have expressed their commitment to wider deployment of telemedicine, most telemedicine initiatives are small-scale projects that are not integrated into healthcare systems.

Aplicatiile medicale
- Progresele realizate in domeniul tehnologiilor de telecomunicatii utilizate in sistemele de sanatate din ultimul deceniu au extins posibilitatile de dezvoltare a aplicatiilor dedicate acestuia - Astazi, aplicatiile destinate acestui domeniu sunt in extindere datorita posibilitatilor de utilizare a serviciilor video interactive, prin posibilitatile de transmitere si stocare a informatiilor, care au fost realizate in ultimul
timp

I. DEFINITII
Telemedicine Definition 1
- Telemedicine involves the use of modern information technology, especially two-way interactive audio/video communications, computers, and telemetry, to deliver health services to remote patients and to facilitate information exchange between primary care physicians and specialists at some distances from each other

Telemedicine Definition 2
- Telemedicine is health care carried out at a distance

Telemedicine Definition 3
- Telemedicinethe use of advanced telecommunications technologies to exchange health information and provide healthcare services across geographic, time, social and cultural barriers

Telemedicine Definition 4
- The World Health Organization (WHO) makes a distinction between telemedicine and telehealth: telehealth is understood to mean the integration of telecommunications systems into the practice of protecting and promoting health, while telemedicine is the incorporation of these systems into curative medicine

e-Sanatate (e-Health):
The term encompass a range of services that are at the edge of medicine/healthcare and information technology: Electronic Health Records: enable easy communication of patient data between different healthcare professionals (GPs, specialists, care team, pharmacy) Telemedicine: includes all types of physical and psychological measurements that do not require a patient to travel to a specialist. Patients need to travel less to a specialist or conversely the specialist has a larger catchment area. Consumer Health Informatics (or citizen-oriented information provision): both healthy individuals and patients want to be informed on medical topics. Health knowledge management (or specialist-oriented information provision): e.g. in an overview of latest medical journals or best practice guidelines. Examples: physician resources such as Medscape and MDLinx. Virtual healthcare teams: consist of healthcare professionals who collaborate and share information on patients through digital equipment (for transmural care).

 mHealth or m-Health: includes the use of mobile devices in collecting aggregate and patient level health data, providing healthcare information to practitioners, researchers, and patients, real-time monitoring of patient vitals, and direct provision of care (via mobile telemedicine) pHealth or p-Health: personal health, collection of H&S tools for (tele)monitoring of health status of a subject
Medical research uses eHealth Grids that provide powerful computing and data management capabilities to handle large amounts of heterogeneous data Healthcare Information Systems: patient data management, work schedule management and other administrative tasks surrounding health. These tasks are part of eHealth and interface with most eHealth implementations due to the complex relationship between administration and healthcare at Health Care Providers.

 ICT (Information and Comunication Technologies) sunt o prioritate tematica a PC7/FP7 al U.E.: sisteme informatice n servicii publice, dar si a PNCDI II al Romaniei (2007-2013)
E.C.: telemedicine encompasses a wide variety of services: teleradiology, telepathology, teledermatology, teleconsultation, telemonitoring, telesurgery, telenursing and teleophthalmology. Other potential services include call centres/online information centres for patients, remote consultation/e-visits or videoconferences between health professionals. Health information portals (http://www.ehealthnews.eu , http://www.ehealthserver.com ), electronic health record systems [1], electronic transmission of prescriptions or referrals (e-prescription, e-referrals) are not regarded as telemedicine services for the purpose of this Communication. Telemonitoring and teleradiology services are especially outlined as together they encompass most of the challenges that are relevant to the implementation of telemedicine services in general.

Telemonitoring
Telemonitoring is a telemedicine service aimed at monitoring the health status of patients at a distance. Data can be collected either automatically through personal health monitoring devices or through active patient collaboration . Telemonitoring is very useful in the case of chronic illnesses (e.g. diabetes, chronic heart failure, COPD chronic obstructive pulmonary disease). Many of the patients - who are often elderly people - need regular monitoring because of the prolonged duration of their disease, the nature of their health condition and the drugs that they are using. Telemonitoring supports patients and health professionals (Glucoboy).

It also results in less frequent visits to healthcare facilities, with increasing the quality of life for patients and reducing medical costs.

Telemonitoring
Telemonitoring has specific characteristics: - It can contribute to re-organisation and redeployment of healthcare resources, for instance by reducing hospital visits, thus contributing to the greater efficiency of healthcare systems. - It has proven to increase quality of care for patients, in particular chronically ill patients. In the context of an ageing population and an increasing burden of chronic diseases, the benefits and its wider deployment can be crucial. - It requires a coherent approach and partnership involving patients, health professionals, healthcare providers, payers and the industry, to ensure sustainability of the services.

Telemonitoring
Telemedicine Equipment: - Audiostethoscopes - Digital Thermometers - Glucometers - Video Cameras - PulseOximetry Devices - Spyrometers - Digital Tensiometer - Store and Forward Software - Radiology Scaners - Infrared Technologies Exemplificare!!!

 Teleradiology has specific features: It is currently the telemedicine service in the most advanced stage of deployment. It is usually carried out as an outsourced service, on a commercial contract basis. The service can be offered in a national or cross-border mode involving other EU countries or third countries. The most important challenges for teleradiology are to ensure benefits of patient care and overall patient safety. Telemedicine does not in any way reduce the quality of radiology services provided to the citizen.

 The aim is to support Members States in achieving large-scale and beneficial deployment of telemedicine services, by focusing on three strategic sets of actions: building confidence in and acceptance of telemedicine services ; bringing legal clarity ; solving technical issues: broadband access and full connectivity is a prerequisite for the deployment of telemedicine; interoperability and standardisation in telemonitoring ; facilitating market development. These different sets of actions are partially interlinked.

III. STAREA ACTUALA

Romnia Bucureti, Iai, Timioara, Targu-Mures: Firma Romsoft SRL din Iai a realizat nc din 2002, prin finanare n PC5 al U.E. (Proiectul MEDCARE; www.euroines.com ; TELEMON (UMF-Bioinginerie: www.bioinginerie.ro/telemon); TELMES (INSCC Buc.) s.a.; Europa: proiectele (n PC5 i PC6): EPI-MEDICS (pentru detectarea sindromurilor cardiologice), E-REMEDY (telemedicin pentru reabilitarea la domiciliu, folosind Internet), HEALTHMATE i HEALTHSERVICE24 (sisteme mobile de teleconsultare bazate pe calculatoare PDA), INCA (asistarea inteligent a diabeticilor), TELECARE (telemonitorizare folosind senzori de semnale vitale, cu ajutorul telefoniei mobile); Germania, UK, Spania, Scandinavia (Norvegia), Italia s.a. SUA: Code Blue - Universitatea Harvard - este un proiect de referin

 Necesitatea e-sanatatii si telemonitorizarii: numr mare de pacieni bolnavi cronic sau cu risc medical crescut (n U.E. i S.U.A. peste 20% dintre ceteni sufer de o boal cardiovascular i cca. 45% dintre decese se datoreaz acestor boli); >20% dintre adulti diabet sau prediabet (!!); supraveghere postoperatorie; mbtrnirii populaiei (persoane n vrst i eventual singure cca. 72% dintre persoanele peste 70 de ani triesc singure dar 90% dintre ele doresc s fie independente, deci necesit (tele)supraveghere la domiciliu); accesul la ngrijirea sntii pentru persoanele din locuri izolate sau defavorizate socio-economic; reinserie profesionala i incluziune sociala a unor categorii de ceteni.

Studii medicale - 2 studii importante publicate in 2003 si 2007 au analizat sistematic datele din litaratura legate de telemonitorizarea bolilor cardiace cronice - date publicate intre 1966-1993 (Louis, Turner, 2003) - date publicate intre 1966-2006 (Chaudry et al, 2007) Concluzii: - telemonitorizarea reprezinta o strategie eficienta pentru controlul bolilor cardiace cronice, in special al celora cu risc ridicat de infarct

Perspective
- Serviciile de telemedicina la nivel mondial cunosc o crestere semnificativa

- Estimarile facute au estimat o crestere de la 9,8 miliarde dolari in 2010 la 23 miliarde dolari in 2015 (o crestere anuala de peste 18%)

Telenursing
Definition:
- is a subset of telehealth that focuses on the delivery, management, and coordination of care and services using telecommunications technology within the domain of nursing Telehealth nurses use the nursing process to provide care for individual patients or defined patient populations over a telecommunication device. Importantly, the nursing process and scope of practice are the same in telenursing as in traditional nursing practice.

Telenursing
Roles: - monitoring patients with chronic diseases - helping patients manage their symptoms and co-morbidities - coordinating care for patients who require services from numerous health professionals - patient triage

Telenursing
Tehnologii de telecomunicatii folosite: - telefon - videofone

- videoconferinte
- dispozitive de ingrijire la domiciliu - internet

Applications in nursing
Telenursing promises to make nurses more ubiquitous and to expand nursings involvement in primary care. The applications of telemedicine for nursing include the following: - Patient consultations. These can range from a simple follow-up session after a procedure, to patient education as part of a disease management program, to more involved consultations that involve diagnosis and treatment. The tools used may include audio and still or live images to facilitate communication between patient and provider. The Internet allows patients to connect from home, or they might visit a remote clinic staffed by nurses to connect with a physician farther away. Consulting via telemedicine connects patients to medical resources that dont exist in their communities. - Remote monitoring. Devices used by the patient at home can collect and transmit medical data to clinicians for interpretation, so a medical intervention can be planned. These technologies can supplement or, in some instances, replace home nursing visits. When nurses are monitoring patients remotely, they can eliminate travel times and see more patients each day. A large body of evidence suggests that telenursing produces outcomes equal or superior to those seen with traditional clinical encounters.

Applications in nursing
Domeins:
- home nursing: - immobilized patients - patients who lives in remote or difficult-to-reach places - patients with chronic illnesses: COPD, DM, stroke, neural degenerative diseases (Parkinson, Alzheimer d.) - patients in immediate post-surgical situations - the care of wounds, ostomies, handicapded individuals

Applications in nursing
Domeins:
- patient education - nursing teleconsultations - examination of results of medical tests - assistance to physicians in the implementation of medical treatment protocols - training nurses remotly - assisting and training nurses in developing countries - nursing care for soldiers on or near the battlefield - collaborating and mentoring by nurses around the globe

Applications in nursing
Education and career opportunities
Telenursing is a sort of frontier within the nursing field, as its full potential has yet to be explored. So what does it take to become a telemedicine professional? From the clinical aspect, youll use the same skills and competencies required by traditional bedside nursing. Youll still be performing nursing assessments and taking on the role of patient advocate. Its just that technology adds another piece to the puzzle you should be skilled with healthcare informational technology (HIT). Its an added bonus if you can help to design or refine technology-based delivery models, in addition to feeling comfortable with existing and emerging technologies. For this reason, a degree in nursing informatics is useful for those wanting a career in telemedicine. Online nursing programs like those offered by American Sentinel University can help you get the informatics skills you need. Telenursing also offers many opportunities for those with strong nursing leadership skills who want to move into administrative roles. They can oversee or design telemedicine programs, maintain medical data, and supervise other nurses. As telemedicine continues to evolve and become an accepted part of the healthcare system, opportunities for nurses will expand at every level.

Telenursing
Benefits:
- driving down the costs of health care - reducing distances and saving travel time - keeping patients out of hospital - decreasing the number of patients admission to ER - helping to solve increasing shortages of nurses - comfort of own-home - sense of control

Telenursing
Benefits
- education and counceling beneficial - decrease weight (James, 2001) - pre-operative education (Thomas, 2003) - outcomes - patient self-care adherence, medications, health status and satisfaction did not differ from ordinary situation (Jerant, 2003) - remote interpretation and diagnosis with ECG results was just as good as interpretation in person (Scwaab, 2005)

Telenursing
Benefits
- remote home health monitoring
- showed improvement in clinical scale and a significant reduction in emergency visits and medical appointments (Frangou, 2005) - automatic transmission of blood pressure data over telephone lines was efficacious in reducing the mean arterial pressure of patients with establised essential hypertension (Rogers, 2001)

Telenursing
Example: The Case of Mr. H. Mr H, a 76-year-old man who had received open-heart surgery 6 days earlier, was not feeling well. It was Saturday, and he had just had a follow-up visit with his cardiologist the previous day. Ordinarily, a patient in Mr. H's situation might make a trip into the local ED, but Mr. H had what he called "his guardian angel." Mr H. called his nurse on the videophone, as he did every day since returning home from the hospital. Mr. H's telenurse, Brenda, saw that Mr. H was lying on his couch, alert, but complaining of feeling poorly. Brenda asked him if he had chest pain or shortness of breath, both of which he denied. Mr. H transmitted his vital signs with the telemedicine unit. His blood pressure was 98/59, heart rate 72, and blood glucose 147mg/dL. Brenda knew that Mr. H's blood pressure medication had been increased the previous day. She called Mr. H's cardiologist, who then called Mr. H at home and instructed him to readjust his medication dosage again. Brenda called Mr. H back later in the day to check on him and recheck his blood pressure. Mr. H's blood pressure was stable and within normal limits and he was doing well.

Telenursing
- The preceding scenario illustrates the tremendous benefit that telenursing can offer patients who are "in the gap" between cardiac surgery and structured rehabilitation programs. - A recent study evaluated the safety and feasibility of a remote, home-based post discharge cardiac monitoring rehabilitation program for postoperative coronary artery bypass graft surgery patients. Patients received telenursing monitoring visits that included surgical incision assessments, vital sign monitoring (heart rate, pulse oximetry, blood pressure, 3-lead electrocardiography), a standardized, medically approved pain/physical assessment and brief educational interventions and support during each telenursing visit. - Compared with patients who received traditional care, the telenursing monitored patients scored better on measures such as physical function, social functioning, role limitations due to physical health and pain.

Telenursing

LTC Joy Walker, RN, conducts a telenursing monitoring visit with a patient following surgery.

Telenursing
Some nurses are more comfortable with computers and technology than others. Most did not learn about telehealth in nursing school. These 2 facts may explain some of the reticence about telehealth voiced by nurses. "Nurses need to realize that telenursing is here, and it's growing" maintained Schlachter-Fairchild, continuing, "It's not futuristic and it's not science fiction. Telenursing is real, and it's doable. It's not a cold, impersonal replacement for a nurse, but an enhancement to nursing care. Rather than patients feeling more distant from nurses, telenursing actually makes them feel more connected, because the nurse's presence is extended, and there is a sense that someone is watching over them all the time." Bonnie Wakefield agrees, noting that "patients don't always recognize when they are getting into trouble, but they are reassured to know that someone will be calling to check up on them the next day." Patient satisfaction with telenursing, according to Wakefield and Schlachter-Fairchild, is overwhelmingly positive.

Telenursing
Others have even questioned whether nursing care provided electronically, over a distance, is truly nursing practice. There is a misperception that because telenursing, by definition, isn't "hands-on," it isn't nursing. Hutchinson argues that telenursing meets the definition of nursing practice that requires nurses to use knowledge, skill, judgment, and critical thinking achieved through nursing education in providing care. A nurse assessing a patient over the telephone using this information to plan, intervene, and evaluate the outcomes of care, is undoubtedly engaged in the practice of nursing, albeit with a different delivery medium.

 Neajunsuri:

Telenursing

- lipsa interactiunii face-to-face - posibilitatea unor disfunctionalitati tehnologice - riscuri crescute privind securitatea si confidentialitatea datelor medicale - imposibilitatea aplicarii ingrijirilor adecvate anumitor cazuri (ex. managementul medical al unei rani cronice la un pacient cu poliartrita reumatoida sau Boala Parkinson) - posibilitatea de a iesi din aria scopurilor propuse de catre furnizorii de sanatate - dificultate crescuta in a furniza pacientilor informatiile necesare pt a semna consimtamantul informat in deplina cunostinta de cauza - disponibilitatea redusa a tehnologiilor comunicationale in anumite arii geografice

Telenursing
Neajunsuri:
- lipsa de credibilitate si confuzia asupra rolului teleasistentei - selectivitatea teleasistentelor (asistente cu experienta) - formarea teleasistentelor (training) - responsabilitatea angajatorilor de a angaja personal calificat - consideratii legate de politele de asigurare daca pacientii traiesc in alta tara - lipsa de interactiune directa diminueaza calitatea actului medical - ,,tentatia furnizorilor de sanatate de a reduce cheltuielile de sanatate prin inlocuirea intalnirilor directe cu cele de tip telemedicina, chiar si in situatiile care ar impune prima varianta (de ex. nevoia crescuta de suport emotional, atingeri terapeutice) - ingrijorari legate de securitatea si confidentialitatea datelor - deficienta unor date consistente legate de raportul cost-eficienta - potentiale probleme legate de responsabilitatea actului medical

Telenursing
Nurses and Telehealth - 1996: first US study (Horton) on the role of telemedicinetelehealth nurses - major findings: 80% of nurses working in telemedicine/telehealth programs reported directly interacting with all patients - 2000: US Telenursing Role Study - major findings: increase of 600% in number of telenurses active in USA - 2004-2005: International Telenursing Role Study - aimed to survey global telenurses in 130 countries

Telenursing
International Telenursing Role Study Aims: - where telenurses were in the world - telenurses satisfaction with their telenursing role

- specific telenursing knowledge and skilss

- perceptions about effectiveness of telehealth as a nurse extender to affect nursing shortage - demand from telenurses worldwide

Telenursing
International Telenursing Role Study - Where telenurses worked in 2004: - 36 countries around the world - 49 of 50 states in USA - distribution: - USA: 68% - Canada: 10% - Australia: 5% - UK: 4% - Norway: 3,5% - New Zealand: 1,1%

Telenursing
International Telenursing Role Study - Characteristics of telenurses: - 719 nurses (489 USA) completed the survey - age range: 22 to 84 yrs - 43% of telenurses had Advanced degrees in Nursing - 47% were part-time telenurses - 75% would like certification as a way to insure a standard of care and credibility

Telenursing
International Telenursing Role Study - Patients treated by Telenurses: - chronic care: 16% - medical surgery: 14% - pediatrics: 11% - coronary: 9% - psyhiatrics: 8% - obstetrics: 8% - orthopedics: 7% - newborn: 6% - rehabilitation: 6% - other: 9%

Telenursing
International Telenursing Role Study - Satisfaction - 59% of telenurses stated they were more satisfied with their telenursing position than ``regular`` nursing positions they had - AUTHONOMY and INTERACTION were the most important factors contributing to telenurses work satisfaction - WHY ELSE: better hours, new skills, challenging, less physically demanding - WHY NOT: lack of face to face contact with patients, lack of technical support

Telenursing
- International Council of Nurses Telenursing Network (2011) The principal goals of ICN's Telenursing Network are: to serve as a global resource for nurses working or interested in telenursing practice, technology development, policy, standards, education and research; to promote effective networking and linkages, and to enable the sharing of telenursing knowledge and expertise and stimulate reflection on the changing nature of nursing care delivery systems across the globe.

Telenursing
ICN Telenursing Network:
Provides a global forum for addressing issues related to telenursing/telehealth. Promotes awareness of telenursing so that the roles and expertise of telenurses are understood, respected and optimized within the health care system. Promotes telenursing as an accepted means for nurses to extend their reach to patients via the use of information and telecommunications technologies. Assists with the development and sharing of knowledge, tools and guidelines which nurses can use to embed telenursing skills and competencies into their practice. Promotes sound telenursing practice. Examines how telenursing can serve as a nursing force multiplier, extending the reach of nurses to more patients and providing better access to care. Establishes links between ICNs Telenursing Network and those international organizations that promote and support the use of telehealth and advanced technologies for telenurses. Provides opportunities for the exchange of knowledge and experience to develop the science and practice of telenursing. Organizes meetings and conferences.

Telenursing
Atributiile unei asistente de telenursing:
-

Triajul diferitelor probleme de sanatate Furnizarea de informatii medicale clientilor folosind protocoale sau algoritme bine definite Promovarea autoingrijirii pacientilor prin furnizarea de informatii medicale Sa raspunda la intrebarile pacientilor prin telefon sau prin mesaje de email securizate Sa ofere informatii specifice legate de boala si consiliere adecvata Sa faciliteze consultatii prin audio si videoconferinte cu furnizorii de sanatate sau intre acestia si clientii lor (de ex. clinici rurale, stabilirea statusului clinic al pacientilor cu boli cronice insuf.cardiaca, diabet zaharat etc)

Telenursing
Atributiile unei asistente de telenursing:
Folosirea de videocamere in cadrul consultarii cu alti profesionist ai sanatatii pt a transmite imagini relevante ale pacientilor (de ex. gradul de mobilitate a unui membru, statusul unei rani cronice, imagini ale unor leziuni cutanate) Sa transmita informatii vitale despre pacienti, de ex. ECG Sa utilizeze echipamente video, computere pt a monitoriza starea de sanatate a pacientilor Sa monitorizeze starea clinica a pacientilor sau a celor externati prematur din spital prin telefon (ex. TA, puls) Sa ofere informatii utile calatorilor legate de destinatiile lor turistice Sa foloseasca videoconferinte pt a oferi educatie continua de nursing Sa creeze site-uri web pt a furniza informatii medicale si consiliere in realtime asupra diverselor aspecte educationale(de ex. renuntarea la fumat)

Telenursing
Calitatile unei asistente de telenursing: - caracteristici personale (atitudine pozitiva, amabilitate deschidere
catre tehnologie) - cunostinte si abilitatea de a utiliza sistemele tehnologice (de ex. capacitatea de a folosi videocamere manuale, echipamente pentru videoconferinte, computere etc) - sa inteleaga limitele tehnologiilor utilizate (de ex. sa fie capabila sa realizeze daca semnele vitale sunt monitorizate adecvat de catre dispozitive speciale) - abilitatea de a recunoaste situatiile in care abordarea telemedicala nu este adecvata nevoilor pacientului - abilitatea de a modifica planul de ingrijire al pacientului - abilitati de colaborare multidisciplinara

Telenursing
Calitatile unei asistente de telenursing:
- constientizarea riscurilor pacientului asociate telemedicinei si initierea de planuri de rezerva - cunoasterea, intelegerea si aplicarea protocoalelor operationale specifice telenursingului si a diverselor proceduri - aptitudini speciale de comunicare - comportament adecvat telefonic/videofonic - constientizarea practicarii nursingului pe baza evidentelor, precum si a domeniilor care inca necesita cercetare - abilitatea de a oferi servicii competente de nursing prin evaluari regulate ale propriei competente, identificand arii de studiu care sa surmonteze deficientele existente - cunostinte care sa permita evaluare clinica adecvata (``to smell emergencies`` - 3-5 ani de experienta)

Telenursing
Structura patologiilor intalnite la om s-a schimbat in ultimele decenii (de la boli infectioase acute si cronice catre boli legate de stilul de viata) Pe masura ce creste speranta de viata, proportia acestor boli devine tot mai evidenta WHO a anuntat ca un numar tot mai mare de oameni sufera de o serie de boli cronice care sunt responsabile de 60% din decese Acesti pacienti au si vor avea nevoie de o paleta tot mai larga de ingrijiri medicale, adaptate nevoilor individuale Consecinta directa este acordarea unei atentii speciale domeniului telenursing ca o modalitate noua de a furniza ingrijire medicala continua pt acesti pacienti

Telenursing
Boli cronice in relatie cu telenursingul: - diabetul zaharat - hipertensiunea arteriala - insuficienta cardiaca - cardiopatia ischemica cronica - bronhopneumopatia obstructiva cronica - cancerul - boli neurologice degenerative - SIDA

Telenursing in Diabetul zaharat

Diabetul zaharat
- sindrom cuprinzand un grup heterogen de tulburari, care pot avea o etiologie diferita, dar care au in comun hiperglicemia, asociata cu modificari lipidice si proteice la fel de importante

Telenursing in Diabetul zaharat

Clasificare - DZ insulino-dependent (tip 1) - DZ insulino-independent (tip 2) - Scaderea tolerantei la glucoza

Telenursing in Diabetul zaharat

Risc crescut pt DZ tip 1:
- predispozitie genetica: frati, surori - microsomie fetala - menarha intarziata

Risc crescut pt DZ tip 2:

- Rude de grad I cu DZ tip 2 - obezitatea - macrosomia fetala (risc pt mama) - cresterea tranzitorie a glicemiei in diferite conditii (sarcina, tratamente diuretice, infectii, contraceptive)

Diabetul zaharat tip 1

Tablou clinic
- debut inainte de 35-40 ani - coma acidocetozica: 75% - starea de constienta afectata in grade variabile (majoritatea se interneaza ``pe picioare``) - deshidratare (limba prajita, turgor prelungit, hTA) - respiratie acidotica (Kussmaul) - halena acetonemica - manifestari digestive: greturi, varsaturi, dureri - cei 3 P: poliurie, polidipsie, polifagie - scadere ponderala

Diabetul zaharat tip 2

Tablou clinic
- debut dupa 40 ani
- poliurie, polidipsie, polifagie: 30% - diagnosticat intamplator (analize uzuale) sau cu ocazia unei intercurente: infectii, IMA, stres psihic - obezitate: 80% - cetoacidoza apare foarte rar!!!

Telenursing in Diabetul zaharat

Evaluarea paraclinica a diabetului:
- examinari de laborator ale sangelui: - glicemia (70-110mg/l) Diagnostic pozitiv: 1. o glicemie > 200mg% 2. doua glicemii >127mg% 3. glicemia 110-126mg% TTOG Tehnica TTGO Se recolteaza sange pentru glicemie AJ (inainte de masa) dupa care se administreaza 75gr glucoza pulvis dizolvata in 200ml de apa. Dupa prima recoltare pacientul inghite glucoza. Timpul in care pacientul inghite nu trebuie sa depaseasca 5 minute. La 2 ore dupa administrarea glucozei se recolteaza din nou sange pentru glicemie. Se considera diagnostic pozitiv atunci cand valorile glicemiei la 2 ore dupa administrarea de glucoza este mai mare sau egal cu 200mg%.

Telenursing in Diabetul zaharat

- rezerva alcalina care se recolteaza pe anticoagulant cu heparina. Valoarea normala e de 27mlEq(echivalenti)/litru si scade in diabetul zaharat decompensat. - hemoglobina glicozilata (HbA1C) care se recolteaza la fel ca si hemograma pe vacutainere specifice pentru hemograma cu anticoagulant EDTA - valoarea normala a hemoglobinei glicozilate: 4-6,5% la adulti iar la copii pana la 6%. Glicata ne arata controlul glicemiei in ultimele 6 luni.

Telenursing in Diabetul zaharat

examene de laborator ale urinei
- glicozuria care arata prezenta glucozei in urina Recoltarea glicozuriei: - Glicozuria se recolteaza din urina colectata pe 24h din care se trimit la laborator 150-200ml dar pe bilet se noteaza intreaga cantitate de urina eliminata. In diabetul decompensat va aparea glucoza pozitiva. - corpii cetonici sau cetonuria care se recolteaza, se eticheteaza si se trimite la laborator in mod similar. Din aceeasi urina se poate cere si glicozurie si dozarea corpilor cetonici Prezenta corpilor cetonici in urina o intalnim in coma diabetica si la pacientii cu varsaturi multiple

Telenursing in Diabetul zaharat

Explorari functionale utile bolnavului diabetic
- EKG - Ecocardiografia - Ecografia si radiografia renala - Ecografia abdominala (ficat, pancreas, colecist) - Examenul fundului de ochi pentru evidentierea modificarilor arterelor retiniene (retinopatia diabetica) - Examenul acuitatii vizuale - Oscilometria pentru determinarea circulatiei periferice - Ecodoppler arterial al membrelor inferioare - Examenul neurologic pentru descoperirea polineuropatiei diabetice

Complicatiile diabetului zaharat

Complicatii cronice
1. Nefropatia diabetica:
- duce la insuficienta renala cronica (principala cauza de deces la pacientii diabetici) - diagnostic: - clearance la creatinina - uree, creatinina - proteinurie

Complicatiile diabetului zaharat

Complicatii cronice
2. Retinopatia diabetica - principala cauza de cecitate < 60 ani - 80-90% din pacientii cu vechime > 30 ani - evidentiata de catre oftalmolog (FO)

Complicatiile diabetului zaharat

Complicatii cronice
3. Neuropatia diabetica - polineuropatii periferice - neuropatia vegetativa (organe interne) - majoritatea evolueaza cu SEMNE CLINICE NEGATIVE (scaderea sensibilitatilor)

Complicatiile diabetului zaharat

Complicatii cronice
4. Gangrena diabetica - leziunile trofice ale piciorului reprezinta una din cele mai grave probleme medicale - > 50% din amputatiile netraumatice ale membrului inferior sunt cauzate de diabet - majoritatea amputatiilor diabetice sunt PREVENIBILE

Complicatiile diabetului zaharat

Complicatii cronice
4. Gangrena diabetica
- 3 factori implicati: neuropat, vascular, infectios - 2 tipuri: - gangrena umeda extensiva: - instalare brusca, pacient febril, stare gen alterata - tumefactie a labei piciorului, semne inflamatorii - gangrena uscata: - instalare progresiva, pe fond de ischemie cronica - haluce/calcaneu: culoare vinetiu-negricioasa, cu sau fara dureri, afebril - ulcerul trofic: localizat la nivel plantar sau la nivelul gambei, in jumatatea inferioara

Complicatiile diabetului zaharat

Complicatiile cronice
5. Macroangiopatia diabetica
- cardiopatia ischemica cronica - infarctul miocardic - arteriopatia obliteranta a membrelor inferioare - accidentul vascular cerebral

Complicatiile diabetului zaharat

Complicatii cronice
6. Alte complicatii - afectarea cutanata: xantoame, buloza etc - osteoartropatia diabetica - complicatii osteo-tendino-articulare - boala Dupuytren - parodontopatia - infectiile cutanate, respiratorii, urinare - hepatopatia diabetica

Complicatiile diabetului zaharat

Complicatii acute
1. Coma acidocetozica (cetoacidoza diabetica)
- la DZ tip 1 2. Coma hiperosmolara - la DZ tip 2 3. Coma hipoglicemica

Complicatiile diabetului zaharat

Coma hipoglicemica
- Semne de hipoglicemie:
- foame intensa - cefalee - slabiciune - ameteli - tulburari vizuale - iritabilitate - transpiratii reci - tremuraturi - confuzie - coma

Tratamentul in Diabetul zaharat

Masuri de profilaxie primara
- identificarea pacientilor cu risc crescut de DZ
- depistarea pacientilor cu DZ in stadii incipiente

Telenursing in Diabetul zaharat

Masuri de profilaxie secundara
- dispensarizarea bolnavilor cu diabet zaharat pentru controale periodice de laborator si clinice. - invatarea pacientului sa-si administreze corect medicatia fie ca este vorba de medicatie orala sau injectabila (insulina) - invatarea pacientului despre regimul alimentar destul de strict pe care trebuie sa il urmeze un diabetic - invatarea pacientului sa evite toxicele: alcoolul, fumatul - invatarea pacientului sa evite eforturile fizice mari, obezitatea - invatarea pacientului sa-si monitorizeze glicemia la domiciliu

Telenursing in Diabetul zaharat

Masuri de profilaxie tertiara
- In cazul aparitiei unor complicatii invalidate cum ar fi: - arteriopatia diabetica care intr-un final duce la obturarea vaselor de sange si intr-un final la amputare, - retinopatia diabetica, - ajutam la readaptarea individului in familie si in societate

Masuri de profilaxie de gradul 4

- In stadiile finale ale bolii asigurarea unei morti demne, linistite

Plan de ingrijire a pacientului cu diabet zaharat Culegerea de date si circumstante de aparitie - persoane cu risc genetic - persoane cu boli care scad rezerva functionala a pancreasului - persoane care fac tratamente cu citostatice, imunosupresoare care inhiba sinteza insulinei

Telenursing in DZ
Manifestari de dependenta (Semne si simptome)
-poliurie -polidipsie -polifagie -scaderea ponderala -astenie fizica si intelectuala -crampe musculare -prurit in sfera genitala si infectii genitale care nu raspund la tratamentele obisnuite -manifestari diverse: plagi greu vindecabile, furunculoza

Telenursing in DZ
Diagnostice de nursing
-alimentatie inadecvata datorita polifagiei accentuate -deshidratare datorita poliuriei -intoleranta la activitate fizica si intelectuala datorita asteniei -anxietate legata de complicatiile bolii

Telenursing in DZ
Diagnostice potentiale
-risc de infectii -risc de complicatii acute : coma hipoglicemica sau coma hiperglicemica -risc de complicatii cronice: scaderea acuitatii vizuale(retinopatie), lipsa de irigare in membrele inferioare(arteriopatie diabetica care duce la gangrena), afecteaza rinichii (nefropatie diabetica manifestare prin proteinurie), furnicaturi, arsuri, dureri, hipersensibilitate cutanata care poate duce la ulceratii si gangrene (neuropatie diabetica) -risc de complicatii: infectii virale sau microbiene din cauza imunitatii scazute -risc de tulburari digestive: diaree sau constipatie -risc de tulburari sexuale: impotenta la barbati si frigiditate la femei

Telenursing in DZ
Obiective
-mentinerea echilibrului metabolismului glucidic -pacientul sa se alimenteze in raport cu nevoile sale cantitativ si calitativ pe 24h -pacientul sa-si recapete conditia fizica si intelectuala -pacientul sa fie hidratat corspunzator in functie de eliminare -pacientul sa fie constient de importanta regimului alimentar -pacientul sa cunoasca semnele de hipoglicemie, hiperglicemie -pacientul sa fie ferit de complicatii acute sau cronice -sa se obtina un echilibru psihic al pacientului -in ingrijirea pacientului sa se implice si familia daca este cazul

Evaluarea pacientului diabetic

1. Activitatea/odihna - simptome:
- astenie, fatigabilitate, dificultati de mers, crampe musculare, tonus muscular scazut - semne: - scaderea fortei musculare

Evaluarea pacientului diabetic

2. Circulatia - simptome
- senzatie de ``picioare reci``, parestezii - semne - piele calda, uscata, rosie

Evaluarea pacientului diabetic

3. Integritatea ego-ului - simptome: - dependenta de altii - semne: - anxietate

Evaluarea pacientului diabetic

4. Eliminari: - simptome - poliurie, nicturie - semne - urina diluata, poliurie

Evaluarea pacientului diabetic

5. Hrana/Aport hidric
- simptome:
- inapetenta, greturi, varsaturi, nerespectarea dietei, scadere ponderala - semne - tegumente uscate, turgor prelungit

Evaluarea pacientului diabetic

6. Durere/confort - simptome:
- dureri la nivelul leziunilor tegumentare
- semne: - grimase, priviri foarte atente la contactul cu leziunile

Evaluarea pacientului diabetic

7. Consiliere/invatare - simptome: - factori de risc familiali - boli cardiace - AVC - HTA - vindecari dificile ale ranilor - folosirea unor medicamente hiperglicemiante (diuretice tiazidice, betablocante)

Diagnostice de nursing in diabetul zaharat

- Deficitul volemic - Nutritie inadecvata - Risc de infectii - Fatigabilitate - Deficitul informational

Diagnostice de nursing in diabetul zaharat

Deficitul volemic - diureza osmotica - diaree - varsaturi - deficit de aport

Diagnostice de nursing in diabetul zaharat

- Nutritie inadecvata
- scaderea aportului alimentar
- anorexie - greturi - dureri abdominale - status hipermetabolic - eliberarea hormonilor de stres

Diagnostice de nursing in diabetul zaharat

Risc de infectii
- deprimarea imunitatii
- modificari ale circulatiei - hiperglicemie - proceduri invazive - leziuni tegumentare

Diagnostice de nursing in diabetul zaharat

Fatigabilitate
- productie energetica scazuta
- modificari ale biochimiei sangelui - deficienta de insulina - cresterea nevoilor energetice - infectii

Diagnostice de nursing in diabetul zaharat

Deficitul informational - despre conditiile, prognosticul si tratamentul
diabetului zaharat in legatura cu interpretarea gresita a informatiilor sau din surse dubioase

Interventiile asistentei in ingrijirea pacientului diabetic 1. Deficitul volemic Obiective - pacientul sa prezinte o imbunatatire in balanta hidrica:
- diureza normala - semne vitale stabile - puls periferic adecvat - turgor normal - mucoase umede

Interventiile asistentei in ingrijirea pacientului diabetic 1. Deficitul volemic

Interventii
- monitorizarea semnelor vitale - masurarea tensiunii arteriale ( hipovolemia se manifesta prin hTA, tahicardie) - monitorizarea temperaturii, culoarea tegum (febra, frisoanele, transpiratiile apar frecvent in infectii, la fel eritemul locoregional) - evaluarea pulsului, turgorul, hidratarea mucoaselor - monitorizarea balantei hidrice (aport/eliminare) - monitorizarea greutatii corporale - corectarea imbalantei hidrice (aport crescut de lichide)

Interventiile asistentei in ingrijirea pacientului diabetic 2. Nutritie inadecvata Interventii:

- determinarea greutatii corporale - realizarea unui program dietetic in corelatie cu posibilitatile financiare ale pacientului - auscultatia sunetelor intestinale, prezenta durerii abdominale, greturi, varsaturi - observarea semnelor de hipoglicemie (alterari ale constientei, foame, transpiratii, ameteli)

Interventiile asistentei in ingrijirea pacientului diabetic 3.Riscul de infectii Interventii

- identificarea semnelor de infectie/inflamatie: - febra, roseata, puroi la nivelul ulcerelor, sputa purulenta, urina tulbure - prevenirea infectiilor (spalat adecvat pe maini) - mentinerea asepsiei in timpul procedurilor invazive - ingrijire adecvata a tegumentelor - pozitionarea pacientului in semisezand - sfaturi legate de administrarea antibioticelor - monitorizarea evolutiei ulcerelor

Interventiile asistentei in ingrijirea pacientului diabetic

4. Fatigabilitatea
- sfaturi legate de alternarea judicioasa a perioadelor de activitate cu cele de odihna - consultarea unui diabetolog in cazul persistentei fatigabilitatii

Interventiile asistentei in ingrijirea pacientului diabetic

5. Deficitul informational Interventii
- stabilirea nivelului de cunostinte legate de boala al pacientului si al familiei - oferirea de explicatii legate de boala si de unele simptome/semne prezentate de pacient - incurajarea pacientului si familiei sa acorde o atentie deosebita dietei

Dieta in Diabetul zaharat

- Este cel mai constant element terapeutic - Este indispensabila tuturor formelor de DZ - Peste 30% din diabeticii de tip 2 sunt echilibrati doar prin dieta - Trebuie individualizata in functie de varsta, sex, activitate fizica, preferinte alimentare, disponibilitati financiare, boli asociate

Dieta in Diabetul zaharat

Recomandari nutritionale:
1. calorii: - normocalorica la normoponderali - hipocalorica la obezi - hipercalorica la subponderali 2. glucide: - 50-55% din aportul caloric - se evita glucidele cu absorbtie rapida, produsele rafinate (zahar) 3. fibre alimentare: predominanta in dieta a glucidelor complexe (legume, cereale, fructe)

Dieta in Diabetul zaharat

Recomandari nutritionale:
4. lipide: - 30% din calorii 5. proteine: - 12-15% din calorii 6. sodiu: - <7g/zi; la hipertensivi <3g/zi 7. alcoolul: ocazional, in cantitati mici 8. edulcorante: zaharina, aspartam, ciclamat 9. mesele: fractionate, 3 mese principale, 2 gustari